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Health Information : Management of a Strategic Resource

by: Abdelhak, Grostick, Hanken & Jacobs

Health Information : Management of a Strategic Resource

by: Abdelhak, Grostick, Hanken & Jacobs

ISBN 13:
9780721686479
ISBN 10:
0721686478
Edition: 2nd
Format: Hardcover
Copyright: 12/11/2000
Publisher: Saunders
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Summary

This book has been thoroughly revised and updated to reflect the vast technological changes in the field for 2-year or 4-year health management programs. This text focuses on health data, its collection and use. It emphasizes the deployment of information technology and the role of the HIM professional in the development of the electronic health record.

SECTION I Foundations of Health Information Management

Health Care Systems

(46)

Midge Noel Ray

Evolution of Health Care Systems in the United States

(1)

Historical Development

(5)

Early Forms of Health Care---2700 BC to the Eighteenth Century

(1)

Health Care in the Nineteenth Century

(1)

Twentieth-Century Reforms

(1)

Complexity of Health Care Today

(2)

Healthy People 2000

(1)

Regulatory Agencies and Organizations

(6)

Federal Government as Regulator

(2)

Role of States

(1)

Legislation

(1)

Accreditation

(1)

Regulatory Mechanisms of Health Occupations

(1)

Health Care Delivery Systems

(18)

Issues and Trends

(1)

Continuum of Care

(1)

Ambulatory Care

(3)

Hospitals

(10)

Home Care (Home Health Care)

(1)

Long-Term Care Facilities

(1)

Hospice Care

(1)

Adult Day Care Services

(1)

Subacute Care

(1)

Mobile Diagnostic Services

(1)

Contract Services

(1)

Multihospital Systems

(1)

Health Care Reform of the 1990s

(1)

Health Care Professionals

(5)

Health Care Team

(5)

Health Care Team Models for Care

(1)

Financing Health Care

(5)

Reimbursement

(2)

Government's Role as Payer

(1)

Managed Care

(2)

Utilization Review

(1)

Technology in Health Information

(2)

Point-of-Care Clinical Information Systems

(1)

Electronic Data Interchange

(1)

Other Information Technology

(1)

Institute of Medicine

(1)

Future Issues

(3)

The Health Information Management Profession

(24)

Shirley A. Eichenwald

Him---A Profession in Transformation

(2)

The Profession Defined

(1)

Him Roles in the Workplace

(2)

The Patient Record---A Valuable Primary Source of Health Data and Information

(1)

Forces Influential in the Evolution of Patient REcords

(3)

From the Beginning to 1900

(1)

From 1900 to Today

(2)

The Evolving Patient Record System

(1)

External Influences on the Him Profession

(4)

Voluntary Standards and Regulations

(1)

Medicare and Medicaid

(1)

Tax Equity and Fiscal Responsibility Act

(1)

Health Insurance Portability and Accountability Act

(1)

Computer Technologies

(1)

Malpractice Claims

(1)

Health Care Reorganization

(1)

Development of the Him Profession

(3)

Formation of the Association

(1)

Development of Formal Educational Programs

(1)

Accreditation of Educational Programs

(1)

Certification and Registration Programs

(2)

RRL to RRA to RHIA

(1)

CRL and FHIMA

(1)

ART to RHIT

(1)

Certified Coding Specialist Credentials---CCS and CCS-P

(1)

Continuing Education Requirements

(1)

The Ahima Today

(2)

Structure

(1)

Membership

(1)

Mission

(1)

The Professioal Code of Ethics

(1)

Looking to the Future

(5)

SECTION II Health Care Data

Data Collection Standards

(72)

Mary Spivey Teslow

Donna J. Wilde

Health Data Users and Decision Making

(2)

Users and Uses of Health Data

(2)

Decision Making

(1)

Overview of the Patient Record

(1)

The Unique Roles of the Patient Health Record

(1)

Definitions

(1)

Data Collection Standards

(12)

Nongovernmental

(1)

Governmental

(11)

Basic Principles of Data Collection

(10)

User Needs

(1)

General Forms and Views

(9)

Format Types

(1)

Methods to Ensure Data Quality

(3)

Record Content Review and Retrospective Completion

(3)

Data Quality Monitoring Methods and Solutions

102

(5)

Quality Assessment and Improvement Study of Patient Record Documentation

102

(1)

Special Concerns of Alternative Care Settings

103

(1)

Clinical Staff Activities Related to Data Quality

104

(1)

Facility Structure That Encourages Data Quality

105

(1)

Characteristics of Data Quality

105

(2)

Data Needs Across the Health Care Continuum

107

(21)

Minimum Data Sets

107

(1)

Ambulatory Care

108

(5)

Acute Care

113

(1)

Long-Term Care

114

(5)

Rehabilitation

119

(1)

Home Health Care

119

(7)

Hospice

126

(1)

Behavioral Health

127

(1)

Computerized Patient Record Initiatives

128

(4)

ASTM E1384 Content Guide for Computer-Based Patient Records

128

(1)

ASTM E1384 Major Segments

129

(3)

Summary and Management Issues

132

(3)

Appendix A Sample Health Record Reports

135

(8)

Appendix B Recommended Joint Commission Documentation Review Criteria

143

(2)

Data Quality and Technology

145

(32)

Donna J. Wilde

Mary Spivey Teslow

Database Structure and Model

146

(6)

Data Model

146

(1)

Characters, Fields, Records, and Files

146

(1)

Types of Data

147

(1)

Selection of Appropriate Type of Data Management Software

148

(4)

Data Quality and Computer Systems

152

(6)

Issues and Characteristics

152

(2)

Design of Computer Systems to Ensure Data Quality

154

(4)

Design and Control of Paper Forms and Computer Views

158

(1)

Forms and Computer Views

158

(8)

Forms or Views Team

159

(1)

General Design Principles

159

(6)

Other Display Features

165

(1)

General Control Principles

166

(1)

Forms/Views Summary

166

(1)

Report Accuracy

166

(1)

Testing Database Program Design

167

(1)

Backup and Data Retention

167

(1)

Data Security Procedures

168

(1)

Documentation of Instruction to Support the Database

168

(1)

Training

168

(1)

Data Quality Monitoring Methods and Solutions

168

(1)

Architecture

168

(4)

Hardware

168

(1)

Electronic Data Entry Technology

169

(3)

Output

172

(1)

Software

173

(1)

Communications

174

(1)

Local Area Networks

174

(1)

Wide Area Networks

174

(1)

Client-Server Technology

174

(1)

Internet

174

(1)

Summary

175

(2)

Data Access and Retention

177

(52)

Lynn Kuehn

Darice M. Grzybowski

Access and Retention of Paper-Based Records

178

(22)

Record Identification

178

(1)

Filing Equipment

179

(3)

Space Management

182

(1)

Filing Methodologies

182

(3)

Master Patient Index

185

(3)

Records Management Issues

188

(6)

Record Tracking

194

(4)

Record Retention

198

(2)

Disaster Recovery for Paper-Based Records

200

(1)

Computer Technology in Automated Data Access and Retention

200

(5)

Hardware

201

(1)

Input, Output, and Storage Devices

201

(1)

Terminals and Workstations

201

(1)

Pen-based Devices

202

(1)

Document Imaging Devices

203

(1)

Voice Recognition

203

(1)

Communications

204

(1)

Client Server Technology

205

(1)

Access and Retention of Image-Based Records

205

(24)

Micrographics

205

(9)

Optical Image Processing

214

(15)

Coding, Classification, and Reimbursement Systems

229

(34)

Elizabeth D. Bowman

Importance of Coding

230

(1)

Coding

230

(1)

Purposes of Coding

230

(1)

Nomenclatures

230

(1)

Classification Systems

231

(1)

Coding Systems in Use

231

(3)

International Classification of Diseases

231

(1)

HCFA Common Procedural Coding System

232

(2)

Coding Systems and Reimbursement

234

(1)

Inpatient Coding Process

234

(2)

Diagnosis Related Groups

236

(5)

Effect of the DRG Reimbursement System on the Inpatient Coding Process

240

(1)

Coding Outpatient or Ambulatory Care Records

241

(4)

Ambulatory Care Reimbursement Systems

243

(2)

Impact of Computers on the Coding and Reimbursement Process

245

(1)

Ethical Problems in Coding

245

(3)

Quality of Coded Data

248

(2)

Elements of Quality Coding

250

(1)

Causes of Errors in Coding

250

(1)

Failure to Review Entire Record

250

(1)

Selection of Incorrect Principal Diagnosis

250

(1)

Selection of Incorrect Code

251

(1)

Coding Diagnoses or Procedures Not Validated by Record Content

251

(1)

Clerical Errors in Database or on Bill

251

(1)

Improving the Quality of Coding

251

(1)

Developing Coding Policies

251

(1)

Quality Improvement Studies

251

(1)

Documentation Guidelines

252

(1)

Measuring Coding Productivity (Quality and Quantity)

252

(1)

Considerations in Hiring Coders

252

(2)

Determining the Number of Coders Needed

254

(1)

Training Coders

254

(1)

Retention of Coders

255

(1)

Coding Resources

255

(1)

Use of Contract Coding and Drg Review Services

256

(1)

Other Coding and Classification Systems

256

(2)

Diagnostic and Statistical Manual of Mental Disorders

257

(1)

International Classification of Diseases for Oncology

257

(1)

Systematized Nomenclature of Human and Veterinary Medicine International

257

(1)

Read Codes

257

(1)

LOINC Codes

257

(1)

Case Mix and Severity of Illness Systems

257

(1)

Future of Coding

258

(5)

SECTION III Data Management and Use

Registries

263

(44)

Sue Watkins

History and Development of Cancer Registries

264

(2)

Hospital Cancer Registries

264

(1)

Population-Based Registries

264

(2)

Hospital Cancer Registry Model

266

(20)

Database Development and Management

266

(8)

Patient Follow-Up

274

(4)

Space, Equipment, and Supplies

278

(2)

Automation

280

(1)

Confidentiality and Release of Information

281

(1)

Policies and Procedures

281

(2)

Use of Cancer Registry Data

283

(2)

Staffing

285

(1)

Approved Cancer Program

286

(2)

Cancer Committee

286

(1)

Cancer Conferences (Tumor Boards)

287

(1)

Documentation

287

(1)

National Cancer Registrars Association, Inc.

288

(1)

AIDS Registries

288

(4)

Database Management

288

(3)

Automation

291

(1)

Uses of AIDS Registy Data

291

(1)

Birth Defects Registries

292

(1)

Database Management

292

(1)

Diabetes Registries

293

(5)

Database Management

295

(2)

Automation

297

(1)

Follow-Up

297

(1)

Use of Diabetes Registry Data

297

(1)

Implant Registries

298

(2)

Organ Transplant Registries

300

(1)

Database Management

300

(1)

Quality Assurance

300

(1)

Training

301

(1)

Trauma Registries

301

(6)

Database Management

301

(1)

Automation

302

(1)

Quality Control

303

(4)

Statistics

307

(33)

Valerie J. M. Watzlaf

Elaine Rubinstein

Overview of Statistics and Data Presentation

308

(1)

Role of the Him Professional

308

(1)

Health Care Statistics

308

(14)

Vital Statistics

308

(1)

Rates, Ratios, Proportions, and Percentages

309

(1)

Mortality Rates

310

(6)

Autopsy Rates

316

(1)

Morbidity Rates

317

(2)

Census Statistics

319

(3)

Organizing and Displaying the Data

322

(4)

Types of Data

322

(1)

Types of Data Display

323

(3)

Statistical Measures and Tests

326

(3)

Measures of Central Tendency

326

(2)

Measures of Dispersion

328

(1)

Inferential Statistics

329

(11)

Tests of Significance

329

(7)

Interval Estimation

336

(1)

Sampling and Sample Size

337

(3)

Research and Epidemiology

340

(33)

Valerie J. M. Watzlaf

Overview of Research and Epidemiology

342

(1)

Role of the Him Professional

342

(1)

Designing the Research Proposal

343

(6)

Hypothesis and Research Questions

343

(1)

Review of Literature

344

(1)

Methodology (Draft)

345

(1)

Research Plan

345

(4)

Validity and Reliability

349

(3)

Validity

349

(1)

Sensitivity and Specificity

349

(1)

Reliability

350

(2)

Biases

352

(1)

Confounding Variables

352

(1)

Sampling Variability

352

(1)

Ascertainment or Selection Bias

352

(1)

Diagnosis Bias

352

(1)

Nonresponse Bias

352

(1)

Survival Bias

352

(1)

Recall Bias

352

(1)

Interviewer Bias

353

(1)

Prevarication Bias

353

(1)

Epidemiologic Study Designs

353

(11)

Descriptive Study

353

(8)

Experimental Epidemiology

361

(3)

Use of Computers in Research

364

(2)

Outcome Studies and Epidemiology

366

(7)

Study Procedures

366

(1)

Data Analysis

367

(6)

Quality Management and Clinical Outcomes

373

(53)

Donna J. Slovensky

Purpose and Philosophy of Management in Health Care

374

(7)

Historical Development

375

(1)

Medical Education Reform

375

(1)

Role of the Joint Commission on Accreditation of Healthcare Organizations

376

(1)

Provider Accountability and Outcomes Reporting

377

(1)

National Committee for Quality Assurance

378

(1)

Federal Legislation

378

(2)

Quality Awards

380

(1)

Clinical Quality Improvement

381

(9)

Historical Development

381

(1)

Objectives

381

(1)

External Requirements

381

(1)

Internal Incentives

381

(1)

Clinical Reviews

382

(1)

Other Reviews

382

(2)

Methodology and Models

384

(6)

Quality Improvement

390

(10)

Theoretic and Conceptual Foundations

390

(1)

Quality Management Gurus

391

(2)

Quality Improvement Methods and Models

393

(1)

Quality Improvement Tools

394

(5)

Clinical and Administrative Use of QI Information

399

(1)

Utilization Management

400

(7)

Historical Development

400

(1)

Objectives

401

(1)

External Requirements

402

(1)

Internal Incentives

402

(1)

Program Components

402

(4)

Methodology

406

(1)

Clinical and Administrative Use of UM Information

407

(1)

Risk Management

407

(5)

Historical Development

407

(1)

Objectives

407

(1)

External Requirements

408

(1)

Internal Incentives

408

(1)

Program Components

408

(2)

Methodology

410

(1)

Clinical and Administrative Use of Risk Management Information

411

(1)

Credentialing

412

(9)

Historical Development

412

(1)

Objectives

413

(1)

External Requirements

413

(2)

Internal Incentives

415

(1)

Program Components

415

(2)

Methodology

417

(4)

Clinical and Administrative Use of Credentialing Information

421

(1)

Medical/Professional Staff Organization

421

(5)

Bylaws, Rules, and Regulations

421

(1)

MSO Structure

421

(1)

Executive Committee

422

(1)

Committee Reporting Structure

422

(1)

Clinical and Administrative Use of Committee Information

422

(4)

Health Law Concepts and Practices

426

(49)

Jill Callahan Dennis

Why Are Legal Issues Important to Health Information Management Professionals?

428

(1)

Fundamentals of the Legal System

428

(2)

Sources of Law

428

(2)

The Legal System

430

(6)

The Court System

430

(2)

Cases That Involve Health Care Facilities and Providers

432

(4)

Legal Obligations and Risks of Health Care Facilities and Individual Health Care Providers

436

(39)

Duties to Patients, in General

436

(1)

Duty to Maintain Health Information

437

(1)

Duty to Retain Health Information and Other Key Documents and to Keep Them Secure

438

(4)

Duty to Maintain Confidentiality

442

(3)

Internal and External Users of Health Information

445

(1)

General Principles Regarding Access and Disclosure Policies

445

(16)

Duty to Provide Care That Meets Professional Standards

461

(1)

Duty to Obtain Informed Consent to Treatment

462

(2)

Duty to Provide a Safe Environment for Patients and Visitors

464

(1)

Duty to Supervise the Actions of Employees and the Professional Staff

465

(4)

Contract Liability Issues and the HIM Department

469

(1)

Legal Resources for HIM Professionals

470

(5)

SECTION IV Management

Principles of Management

475

(5042)

W. Jhack Suncan

Peer M. Ginter

Management: Defining the Field

476

(3)

Management as a Process

476

(1)

A Brief History of Management

477

(2)

Understanding Strategic Management

479

(3)

Situational Analysis

479

(2)

Strategy Formulation

481

(1)

Strategic Implementation

481

(1)

Strategic Control

481

(1)

Nature of Managerial Work

482

(2)

Overview of Research

482

(1)

Analysis of Managerial Functions

483

(1)

Five Functions of Management

484

(22)

Planning and Goal Setting

485

(3)

Principles of Effective Planning

488

(1)

Organizing for Action

488

(6)

Another View of Organizing

494

(1)

Principles of Effective Organizing

495

(1)

Making Management Decisions

496

(2)

Essential Principles of Decision Making

498

(1)

Leading and Managing

499

(2)

Principles of Leading

501

(1)

Controlling: Completing the Management Loop

502

(3)

Principles of Management Control

505

(1)

Understanding Job Descriptions

506

(5011)

Evolution of Job Description

506

(1)

Relating Organizational Goals to Job Descriptions

506

(5011)

Operational Management

5517

Carol Enable

Anita Hazelwood

Individual Work Processes (Micro Level)

518

(18)

Organizing Work

518

(1)

Work Distribution Chart

518

(5)

Productivity

523

(3)

Work Simplification or Methods Improvement

526

(10)

Systems and Organizational Level (Midlevel)

536

(5)

Systems Analysis and Design

536

(4)

Organizational Structure

540

(1)

Organization-Wide Level

541

(9)

Project Management

541

(7)

Reengineering

548

(2)

Design and Management of Space in Health Information Services

550

(12)

Work Space Design

550

(4)

Design of the Workstation

554

(8)

Human Resource Management

562

(58)

Wesley M. Rohrer III

Human Resource Management

564

(54)

Navigating Through Turbulent Times

564

(1)

Broad Environmental Forces

564

(1)

Forces Transforming Health Care

564

(1)

Challenges for Health Information Management Professionals

565

(1)

Systems Perspective

565

(1)

Environmental Influences and Human Resource Management

566

(4)

Inputs (Human Resources)

570

(1)

Legal and Regulatory Requirements Affecting Human Resource Management

571

(9)

Internal Environment

580

(4)

Systems Approach Applied to Health Information Services

584

(1)

Systems Perspective Applied to Health Resource Management

584

(34)

Future Issues

618

(2)

Financial Management

620

(34)

Mary Alice Hanken

Historical Perspective

622

(2)

Payment for Health Care Services

622

(2)

Setting Priorities for Financial Decisions

624

(1)

Mission

624

(1)

Goals

624

(1)

Objectives

625

(1)

The Business Plan and Budget

625

(3)

Identifying Trends

626

(1)

Staffing Information

626

(1)

Program and Automation Assessments

626

(1)

The Four M's

626

(1)

Developing the Bushiness Plan and Budget

627

(1)

Budgets

628

(3)

Statics Budget

628

(1)

Operating Budget

629

(1)

Master Budget

629

(1)

Who Participates in Budget Development?

629

(1)

Budget Periods and Types

629

(1)

Budgeting for Staff

630

(1)

Using the Budget as a Control

630

(1)

Participating in the Management of Revenue

631

(4)

Charge Master

631

(2)

Claims Analysis

633

(1)

Case Mix Analysis

634

(1)

Revenue Versus Cash

634

(1)

The HIM Professional's Role in the Cash Budget

634

(1)

Patient Accounting

635

(1)

Financial Aspects of Fraud and Abuse Compliance

635

(1)

Cost Allocations

636

(2)

Why Does Allocation Occur?

636

(1)

Allocation Methods

637

(1)

Why Is Cost Allocation Methodology Important for the HIM Professional?

638

(1)

Health Care Accounting and Fiance

638

(2)

Cash and Accrual Systems

638

(2)

Fiscal Periods

640

(1)

Using Financial Reports to Provide Management Information

640

(1)

Using Ratios to Evaluate Financial Data

640

(4)

Liquidity Ratio

643

(1)

Turnover Ratio or Activity Ratio

643

(1)

Performance Ratio

644

(1)

Capitalization Ratio

644

(1)

Capital Expense and Investment Decisions

644

(6)

Capital Expenditures

645

(1)

Capital Request Evaluation Process

645

(1)

Time Value of Mone

645

(1)

Compounding

645

(1)

Discounting

646

(1)

Net Present Value

647

(2)

Accounting Rate of Return

649

(1)

Payback Method

649

(1)

Arguments Pro and Con for Evaluation Methods

650

(1)

Other Phases of Financial Management

650

(4)

Implementing

650

(1)

Seeking Alternatives

650

(1)

Role of the HIM Profession in Financial Management

650

(4)

SECTION V Information Systems

Technology, Applications, and Security

654

(34)

Melissa Saul

Health Information Infrastructure, Technology, and Applications

656

(12)

Scope of Health Information Systems

656

(1)

Computers in Health Care---Past and Present

657

(3)

Computer Fundamentals

660

(1)

Software

661

(7)

Computer Applications

668

(4)

Administrative Applications

668

(1)

Clinical Applications

669

(3)

Emerging Technologies

672

(4)

Inernet

672

(4)

Telemedicine

676

(1)

Fundamentals

676

(1)

Implementation

676

(1)

Telemed---An Example

677

(1)

Computer Security

677

(5)

Authentication Tools

678

(2)

Reporting Capabilities

680

(1)

Physical Security

680

(1)

External Controls

680

(2)

Data Management Technology

682

(6)

Data Mart

682

(3)

Data Modeling

685

(3)

Electronic Health Records: A Unifying Principle

688

(32)

Gretchen F. Murphy

Electronic Health Records, Past and Present

691

(1)

The Present Goal: Computer-Bsed Patient Records (CPRs) to the Electronic Health Record (EHR)

692

(7)

Electronic Health Records to Meet Challenges of Increased Demands

692

(1)

Drawbacks of Using Paper Records

693

(1)

Defining a New Model

694

(1)

More Sophisticated Functionality Through a New Model

694

(2)

EHR Building Blocks: Data and Technology Infrastructure

696

(1)

Vocabularies, Codes, and Text Processing

697

(2)

Strategic Recommendations

699

(1)

Progress Toward an Electronic Health Record

699

(3)

The Electronic Health Record: Is It Still a Dream?

699

(1)

Orders Communication: Better Management of Care and Data

700

(1)

Brigham and Women's Hospital and Partners Healthcare System

701

(1)

New Ideas in Development

701

(1)

Health Information systems and EHRs: Selected Issues and Barriers

702

(4)

Costs

703

(1)

Technology Infrastructure and Customer Expectations

703

(1)

Legislation

703

(1)

Confidentiality and Security

704

(1)

Health Care Information Processing Standards

705

(1)

American National Standards Institute

706

(1)

Managing the Transition: Challenge to Health Information Professions

706

(14)

EHR Working Assumptions: Planning for 2010

712

(1)

Sleeting an Approach to EHR Development

712

(8)

Information Systems Life Cycle

720

(53)

Merida L. Johns

Introduction

722

(1)

System Analysis, Design, and Implementation

722

(1)

Role of the HIM Professional

723

(1)

System Life Cycles

723

(5)

General System Life Cycle

724

(1)

Information System Life Cycle

724

(1)

Information System Life Cycles in the Organization

724

(2)

Aggregate Information Life Cycle of the Organization

726

(1)

System Obsolescence

727

(1)

Information System Development Life Cycle

728

(1)

Analysis

729

(22)

Tools and Aids for System Analysis

729

(11)

Investigate Strategies for Analysis of Requirements

740

(6)

Analysis Document

746

(1)

System Design

747

(1)

Design Principles

748

(3)

Role of Prototyping in System Development

751

(1)

System Implementation

752

(4)

User Preparation and Training

752

(1)

Site Preparation

753

(1)

System Testing and Conversion

754

(1)

Startup

754

(2)

System Evaluation and Benefits Realization

756

(5)

Benefits Realization

757

(1)

Cost-Benefit Analysis

757

(2)

Cost-Effectiveness Analysis

759

(1)

Other Evaluation Methods and Techniques

760

(1)

Purchasing Process: Request for Proposal

761

(12)

Planning Steps Before RFP Preparation

762

(1)

Analyzing System Requirements

762

(1)

Development of System Specifications

762

(1)

Development and Distribution of the RFP

763

(4)

Evaluation Criteria

767

(2)

Demonstrations and Site Visits

769

(1)

System Selecting and Contract Negotiation

770

(3)

Glossary

773

(39)

Index

812

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Health Information : Management of a Strategic Resource

Health Information : Management of a Strategic Resource

9780721686479

0721686478

Summary

Table of Contents

Supplemental Materials

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Amazon no longer offers textbook rentals. We do!

Health Information : Management of a Strategic Resource

Health Information : Management of a Strategic Resource

9780721686479

0721686478

Summary

Table of Contents

Supplemental Materials

Write a Review

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